West Palm Beach Florida car accident Physician’s Determination of Effects of Pain associated with your West Palm Beach Florida car accident Call 1-800-74-TRIALfor help

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Name of Patient __________________________
Name of Referring Physician (if applicable) _____________________

1. Have all available medical records and diagnostic studies been reviewed? If so, summarize records, studies and findings.
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2. Document and provide summary of the patient’s complaints and include patient’s overall pain associated with your West Palm Beach Florida car accident history.
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3. Provide details concerning findings on physical examination.
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4. Provide details concerning findings on neurological examination.
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5. Check and summarize results of all diagnostic studies reviewed and/or ordered.
X-Ray
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Magnetic Resonance Imaging
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Real Time Sonography
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Ultrasound
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Computerized Axial Tomography
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Single Photon Emission Tomography (SPECT Scan)
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Lumbar Puncture
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Arthography
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Angiography
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Bone Scan
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Electroencephalography (EEG)
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Discograms
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Myelograms
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Electromyogram (EMG)
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Cervical Disc Distention Test
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Videofluoroscopy
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Digital Radiography
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6. Have all appropriate and necessary psychological tests been administered? (Where applicable) Detail all tests (including Minnesota Multi-Phasic Personality Inventory and Minnesota Multi-Phasic Personality Inventory II) that have been administered.
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7. Describe diagnostic impression based on all accumulated information. Note and refer to cause and classification of pain associated with your West Palm Beach Florida car accident and provide a description of any biopsychosocial impacts of pain associated with your West Palm Beach Florida car accident and prognoses.
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8. Provide estimate of pain associated with your West Palm Beach Florida car accident and impairment rating, using the procedures set forth in the Guides to the Evaluation of Permanent Impairment.
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9. Provide listing of other professionals consulted as needed (e.g., psychiatrists, psychologists, vocational or rehabilitation specialists).
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10. Determine patient’s functional capacity. (Include review of various daily activities that the person can or cannot perform and determine level of impairment based on physical disability as well as relation to pain associated with your West Palm Beach Florida car accident ).
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11. Have all reports and diagnoses been forwarded to patient’s attorney? Provide dates and manner of communications.
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